Surging Braves hit Frisco

Steve from OH: Dude, you had quite a prolific run of rousing, entertaining posts tonight while I was out feeding my face. Glad I skipped dessert, or else I might be losing it right now from laughing. Well done.

By the way, someone said Cox had his knees replaced a second time. Point of fact, he did not. He merely had a couple of pieces of the hardware in his artificial knees replaced this winter. Quite a bit of difference than having total knee replacement.

Not that his knees have a bit to do with whether he is or isn’t doing a good managing. Because they have zero to do with it. He’s been on the field enough times to get ejected at least five or six times this year, just hasn’t said the magic word or pushed it long enough for it to happen.

That might be mellowing or whatever, but I don’t see where it has anything to do with his knees.

Funny that he gets ripped by some here for arguing and getting, and gets ripped for not arguing and getting ejected by others.

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Oh, and how unbelievable was the Tampa Bay-Cleveland game? Rays blow a 10-run lead and lose 11-10. Fausto Carmona went all Edinson Volquez on us and forgot how to throw a strike. (Rays took 20 consecutive pitches against him at one point. Yes, 20).

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a643dp: Yes, been to a few great shows at the Fillmore, which is a terrific venue, especially since they renovated it in the ’90s. I saw Matthew Sweet there in the late ’90s, and saw Kings of Leon with Secret Machines about 4-5 years ago. The KOL/Secret Machines show was outstanding.

Best show I’ve seen in S.F., though, was The Verve at Bill Graham Theatre. They were one of the hottest bands in the world at the time, with “Bittersweet Symphony” at the top of the alt-rock charts, etc.

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Caveman, the original Scomas is at Fishermen’s Wharf in S.F., the one in Sausalito followed. Yes, eaten at the original, and it’s outstanding, but overpriced and too crowded. Very good food, though.

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N8, Tracy is a Hall of Famer — literally, he’s in the Hall of Fame, as a winner of the Spinks Award given annually to a writer.

That said, if you want to take literally what Bobby says about his knees and about every other medical issue he discusses, you’ll be scratching your head going, “Is that possible?” In other words, he doesn’t always mean literally what he says in some such cases.

I’m not going to get into a big argument over this, because it’s silly. I’ll just give you the note that I wrote after Bobby told several of us writers at Camp Roger, the camp formerly known as Camp Leo, in first week of February:

By DAVID O’BRIEN
dobrien@ajc.com

Bobby Cox walked without pain Friday morning on recently refurbished artificial knees. But the Braves manager was more excited talking another surgically repaired and fully recovered member of the organization, closer Mike Gonzalez.

After missing more than 12 months recovering from ligament-transplant elbow surgery, Gonzalez rejoined the team in June. He pitched in 36 games, converted 14 of 16 saves, and had 44 strikeouts in 33-2/3 innings, but had some typical inconsistency pitchers face after surgery.

“You can only imagine what it’s going to be like after a full offseason of rest,” Cox said of the left-hander, one of six pitchers who participated in the first day of the Braves’ voluntary early pitching camp Friday at Turner Field. “He’s going to be dominant this year.”

Top prospect Tommy Hanson was at camp along with Tim Hudson, who’ll miss most of the 2009 season after elbow surgery; relievers Blaine Boyer and Gonzalez; newcomers Stephen Marek and lefty Eric O’Flaherty; and Anthony Lerew.

Reserve Clint Sammons was the lone catcher on Day 1 of the camp, run by pitching coach Roger McDowell. Seated behind netting around the indoor pitching mounds was Cox, who had more scars but less discomfort after worn pieces of his artificial knees were replaced in October.

“I got new parts,” the 67-year-old manager said, smiling.

NOW, N8, let me ask you: Cox was at the Winter Meetings in Vegas in the first week of December, walking. Do you think a 67-year-old man had full-on, double-knee replacement at some point in October, then walked all over the Bellagio in Vegas during the Winter Meetings, which would have been no more than, oh, six weeks later?

Here’s something from the Univ. of Washington Orthopaedics & Sports Medicine site on initial double-knee replacement surgery:

Same-day double knee replacement

Replacing both knees at the same time.

This is an excellent question, and like many good questions, the answer is somewhat complicated. It is almost always technically possible to replace both knees at once. However, one has to ask: what would be gained or given up by doing this? As of now, there have been a handful of scientific studies that have asked that very question. One of those studies concluded that it is no problem to go ahead and replace both knees at the same time, but most of them came up with a slightly different response: the overall time to full recovery is shortened by doing knees at the same time, but you take some increased risk to gain this advantage. Here’s the summary, as I interpret it:

The benefit of same-day both-knee surgery: The time to full recovery is shorter. If that does not seem intuitive, think about it this way: If you figure it will take between 2-3 months to really start to feel right after a knee replacement, and you do that twice, that’s 4-6 months of total recovery time. If you do them both the same day, you go through the experience once, and the whole thing is behind you in 2-3 months.

The disadvantage of same-day both-knee surgery: The surgical risk appears to be increased. The types of complications that were more common in patients having the knees done together included:

temporary disorientation after surgery,
the need for blood transfusions, and
severe cardiac complications (which can be fatal).

If the complication rates were doubled in same-day both-knee surgery, we’d call that a tie, since you’d have to have the operation twice if you did it on separate surgical dates. However, the complication rates for all the complications listed above are more than double with same-day both-knee surgery. The absolute magnitude of the risk of heart attack is still not huge, but the difference was noticeable; the risk of needing a blood transfusion went up considerably, though. To give you an idea, I very rarely need to give patients blood after a single knee surgery, but it is not at all uncommon if we do both at once. Finally, the overall length of hospital stay may be a bit longer with same-day both-knee surgery.

So, in view of this, why would anyone want to do them both at once? My observation is there are two sets of feelings on the part of patients about this. Some people are risk-averse, and want to minimize the risk as completely as possible; clearly, they would want to do one knee at a time.

Other people are what I call therapy-averse (or pain-averse), meaning they want to minimize the overall length of time they are either in physical therapy (perhaps for work reasons) and the overall length of time they are uncomfortable from the surgery. Provided they don’t mind the increase in risk, these are good candidates for same-day both-knee surgery.

AND HERE’s SOMETHING from the website MEDICALNEWSTODAY, about the complications associated with a second joint-replacement surgery on same joint. Read this and then tell me if you think he had double-knee replacement — for the second time — at some point in Ocober and then went to the winter meetings in Vegas, without a wheelchair or walker:

Joint Replacement The Second Time Around

Americans are getting more new hip and knee implants than ever before nearly a half-million a year. This boom in joint replacement has made the procedure somewhat routine and widely available. But when it comes time to have that initial implant replaced, due to wear or failure, the procedure is anything but routine, according to an article in the March issue of Cleveland Clinic Arthritis Advisor.

“Revision surgery is a far longer and more complex procedure than initial surgery,” says Kenneth Marks, M.D., an orthopaedic surgeon at Cleveland Clinic. “It requires more time and expertise to remove the old implant and do a customized repair and realignment of the existing bone to ensure that the new implant will be held firmly in place.”

Growing demand

Though the challenge of revision surgery is higher, the demand is climbing. More and more patients who got their first new hip or knee at age 55 or 60 are outliving the useful life of their implants.

Advanced age is becoming less of an impediment. Even among people 80 and older, the benefits of joint revision surgery pain elimination, increased mobility, greater range of motion can outweigh the risks, as long as you’re healthy enough to undergo such surgery in the first place.

Why revision?

Though implants may need to be replaced for a variety of reasons, the most common one is loosening. Loosening starts with the tiny particles that eventually wear off the plastic liner or insert within the hip or knee. As some of these particles slowly find their way to where implant meets bone, they get absorbed by cells (macrophages) capable of triggering bone reabsorption (osteolysis). Over time, this dissolving away of bone leads to implant loosening and pain.

Implant designers have slowed the creation of such particles by using harder, cross-linked plastics, and have nearly eliminated them altogether with newer ceramic-on-ceramic and metal-on-metal designs. The result has been increased implant longevity, meaning implants can now be done earlier to meet the longer lifespan of people who get them.

Other less-common reasons revision surgery may be needed include inadequate bone ingrowth, infection, dislocation, and fracture. When hip implants are inserted without cement, they depend on the growth of bone into the porous surface of the implant over time to ensure stability. Should this process not be fully achieved due to poor bone metabolism, the implant can more easily loosen later.

Infections can also be a cause of hip or knee implant removal, either early on, due to bacteria getting into the incision site, or years later, should blood-borne germs reach the implant and prove resistant to antibiotic therapy. Falls leading to fracture, or dislocation can also necessitate removal and replacement of the implant.

Follow the pain

Increasing pain near the implant, or greater difficulty in placing weight on it are early indications that revision surgery may be needed.

“The location of your pain tells us which part of your implant may be loose,” says Dr. Marks. “If it’s more of a groin pain, then the acetabular side is likely the problem. If it’s more of a thigh pain, then the loosening is typically on the femoral side.”

With knee implants, pain just below the knee suggests that the metal implant in the tibia may be loose, but pain that is felt throughout the knee may indicate infection.

Scans show the way

Whatever clues your pain provides need to be confirmed with an X-ray scan. “We can see if there is poor ingrowth on a hip implant, or if the plastic insert in your knee is worn,” says Dr. Marks.

If an X-ray suggests serious bone erosion, such that what remains may not be enough to provide sufficient contact between the bone and new implant, a computed tomography (CT) scan will be done to get a more precise view of the erosion. This will help the surgeon determine what needs to be done to repair the damage before proper alignment of a new implant is possible.

Out with the implant

A variety of factors make hip or knee revision surgery a much more lengthy, complex procedure than the initial surgery. “It’s not unusual for these surgeries to last five to eight hours or more,” says Dr. Marks.

Removing the old implant is a problem not faced the first time around. Not only must the previous device be taken out, but any cement that remains inside the bones must be cleaned out, as well. In hip revisions, the upper shaft of the femur that surrounds the old implant will often be cut away in two or three long sections (osteotomy) to enable implant removal and cleaning of the femoral canal. These pieces later will be reassembled and wired together around the stem of the new implant.

In with bone grafts

The most customized part of a hip or knee revision is the strategy used for restoring the damaged joint surfaces. “There is no one typical way to do this,” says Dr. Marks. “It varies with the degree and location of erosion, and the surgeon’s experience.”

At a minimum, there needs to be at least 50 percent surface contact between bone and the implant for a lasting, secure grip to be possible. Any less and the pits, holes, and other cavities need to be repaired using bone grafts, usually a thick paste of bone chips (morselized bone) made by grinding up cadaver bones.

In a hip revision, bone paste may be used to strengthen the pelvic socket or repair erosion along the inner canal of the femoral shaft. And if the erosion is severe, the socket may need to be rebuilt and reinforced using wire mesh or a titanium ring, in order to regain more normal biomechanics.

In a knee revision, if the end of the femur is weak, even after trimming away damaged bone, the central canal will need to be partially filled with morselized bone. In some cases, metal wedges may be required to better secure the attachment of the new femoral component.

Risks reduced

The many factors that complicate revision surgery less healthy bone, an older patient, greater infection risk, and a customized array of bone, implant, grafts, and support structures mean that it’s easier for at least one of these things to go wrong over time.

“Hip and knee revisions typically last about eight to 10 years, compared to the 20 or more years you can expect with a first-time implant,” says Dr. Marks.

Though still a serious operation, joint revision is not as fraught with risk as it used to be. “We used to discourage revisions due to obesity, advanced age, and other complications,” says Dr. Marks. “But as we’ve gained experience in limiting the risks, we’ve become more permissive. As long as you’re healthy enough to undergo major surgery, you’re healthy enough to have a revision.”

WHAT YOU CAN DO

Don’t overdo it. Excessive and repetitive overloading of your hip or knee implant can lead to premature loosening.

Let the pain guide you. Increasing pain in the area of your implant is the first indication you may need revision surgery.

Seek a specialist. The complications of revision surgery mean that it’s best to seek out a surgeon who does a large number of revisions.

Don’t give up on rehab. Though rehab is similar the second time around, it takes longer to regain muscle strength and range of motion due to additional scarring.

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Bruce, yes, we reported that Omar had what was termed (as usual) “successful” surgery to fix the fracture in his hand. Plate was inserted. No timetable given for return, though two months has been sort of the unofficial estimate given (by Cox the day before the surgery; said they had discussed a minimum of 6-8 weeks to be the expected time without Infante)….

Doc Holliday: Trade involving three teams in order to move Francoeur? Doubtful. For one, three-team trades occur in the NBA, but rarely in baseball, and not for a player of presumably such limited current appeal to other teams (given his contract and production).

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